Provider Demographics
NPI:1891154712
Name:DEDOMINICIS, SUSAN C (MSN, NP-C)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:C
Last Name:DEDOMINICIS
Suffix:
Gender:F
Credentials:MSN, NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:990 PARADISE ROAD
Mailing Address - Street 2:
Mailing Address - City:SWAMPSCOTT
Mailing Address - State:MA
Mailing Address - Zip Code:01907
Mailing Address - Country:US
Mailing Address - Phone:781-595-0151
Mailing Address - Fax:781-592-6780
Practice Address - Street 1:990 PARADISE ROAD
Practice Address - Street 2:
Practice Address - City:SWAMPSCOTT
Practice Address - State:MA
Practice Address - Zip Code:01907
Practice Address - Country:US
Practice Address - Phone:781-595-0151
Practice Address - Fax:781-592-6780
Is Sole Proprietor?:No
Enumeration Date:2016-02-19
Last Update Date:2021-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2290806363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily